Claims Analysis

Many of our Payor customers are asking where to focus and how to prioritize their efforts when applying our data to their Medical Drug management processes. To help each organization understand the potential impact of applying our data, Claims Analysis evaluates your historical claims and provides a summary report which highlights the potential impact of each focus area:

  • Pricing – compare your allowed amounts to the RJ methodology
  • Site of Service Pricing – compare allowed amounts by office, outpatient, etc.
  • Pricing by NPI – rank providers by over-reimbursement volume
  • Max Dosing – identify outliers for FDA and Compendia uses
  • Diagnosis Code – assess the viability of your ICD-9/10 data
  • NOC Codes – determine permanent HCPCS availability

As an example, our Pricing review identifies claims whose pricing exceeds current market or fee schedule rates. Your data can be reviewed to identify rates that could be optimized and claims priced manually at incorrect rates. See chart to the below for an example of what our full report can show. The error rates for your organization may vary, but a typical analysis will identify between 10% and 25%of claims that apply an incorrect fee schedule rate.

Claims Analysis will give your organization an opportunity to review current contracts and policies to ensure pricing is in alignment with current rates and accurate coding is considered in your prioritization of resources. From this analysis, you will be able to leverage RJ Health data in more diverse and strategic ways.

DOWNLOAD FULL SAMPLE REPORT HERE